JVS-vascular insights最新文献

Objective

Endovascular approaches within vascular surgery have grown substantially over the past two decades. As general surgery trainees gain exposure to these approaches, innovative simulation methods to train basic endovascular skills are needed. The purpose of this study was to pilot an existing low-cost model for percutaneous femoral arterial access and examine its effect on resident simulation performance and procedural interest.

Methods

A percutaneous arterial access simulation was designed using an adapted chicken breast model. Exiting postgraduate year 1 and 2 general surgery residents participated in sessions with these models for ultrasound-guided arterial access simulation using 5F micropuncture kits. Vascular surgery faculty and fellows provided didactic introductions and proctoring during sessions. Residents also completed skill self-assessments before and after participating in the simulation and rated the model and simulation as a whole. Paired t tests and descriptive statistics were applied in analyses.

Results

Twenty-six residents participated in the simulation in May 2022. Mean resident confidence in overall ability to complete steps required for percutaneous femoral arterial access increased from 3.1 ± 1.0 to 4.4 ± 0.6 (P < .001) when assessed on a 5-point rating scale. Most improved individual steps were identification of arterial cannulation sites using ultrasound (mean difference, +1.4; 95% confidence interval, 1.0-1.8; P < .001) and advancement of hemostatic sheaths over the guidewire into position (mean difference, +1.5; 95% confidence interval, 1.0, 1.9; P < .001). Residents also reported increased comfort level asking to vascular surgery fellows and faculty to participate in subsequent percutaneous access procedures (mean before, 2.7 ± 1.0; mean after, 3.2 ± 0.7; P = .015). On session evaluations, the majority of residents (n = 19 [86%]) strongly agreed that the model was realistic for training purposes and could be used for future skill assessments (n = 16 [73%]). The average material cost required for creation of one chicken model was estimated at $10.32.

Conclusions

General surgery trainees require opportunities for low-stakes, independent practice of basic endovascular skills, particularly those with applicability beyond vascular surgery. In this study, use of a simple, a low-cost chicken model promoted increases in procedural confidence and was sufficiently realistic for further training with residents. In the future, this model will be incorporated into standardized assessments to ensure translation of simulated skills to live operative settings.

Vascular surgery is a dynamic and complex specialty that requires many years of training and lifelong learning. Traditional education methods may not be sufficient to meet the needs and preferences of learners in this field. Podcasting and other free open-access medical education online materials may provide innovative tools to deliver up-to-date, evidence-based information in an accessible and entertaining format. Many free resources have been developed in the past few years and are now available to vascular surgery learners. The Audible Bleeding podcast is the first and largest podcast in the United States dedicated solely to vascular surgery education. The Society for Vascular Surgery is the leading professional organization for vascular surgeons, with a mission to advance excellence and innovation in vascular health. The Society for Vascular Surgery and the Audible Bleeding podcast have established a successful collaboration that enhances the podcast's quality and promotes the society's mission and vision.

Background

This article aims to outline the process and present preliminary outcomes of a local quality improvement initiative focusing on length of stay (LOS) and 30-day unplanned readmissions in patients undergoing treatment for peripheral arterial disease.

Methods

Initiating with internal data acquisition, our clinical informaticists, adept in Epic data mining, were tasked with monthly query of the database for all patients with peripheral arterial disease managed since May 2021. An automated report of crucial variables, eliminating the need for individual chart review, was thus generated. Studying trends in LOS and readmissions, we set target goals of 7 days for LOS and 11% for 30-day unplanned readmission, referencing the top-decile institutions in the Vizient ranking. To enhance our quality improvement initiative, we formed a comprehensive limb salvage committee, comprising a vascular surgeon, hospitalist, podiatrists, nurses, a case management team, and a clinical researcher. This multidisciplinary team met regularly to review monthly reports, identify trends, and propose improvements. After 6 months of observation, the limb salvage committee finalized a set of recommendations, which were then communicated to the vascular surgery faculty for feedback and subsequent implementation. Monthly outcomes were continuously monitored by the limb salvage committee to assess progress and pinpoint areas necessitating further improvement.

Results

Between May 2021 and March 2023, 985 consecutive procedures were performed. The average postoperative LOS was 7 ± 10 days, with 35% not meeting the goal. Patients not meeting the LOS goal often had a history of coronary artery disease or congestive heart failure and were admitted initially for nonvascular reasons. The readmission rate was 15%. Recommendations from the limb salvage committee included deferring nonurgent revascularization to outpatient care with prehabilitation for at-risk patients, and early follow-up by a nurse practitioner for wound check and pain management. These recommendations were implemented at the end of March 2023. After implementing these recommendations, 272 cases recorded between April and July 2023 saw a decrease in patients not meeting the target LOS to 27%, and unplanned readmissions decreased to 11%.

Conclusions

Our limb salvage quality improvement project has proved efficient in monitoring quality metrics and targeting specific areas in need of improvement. Continuous monitoring is necessary to ensure compliance, track outcomes, and identify areas in need of further improvement. Future studies will assess further the effectiveness of this process in improving patient care.

Introduction

Methods

Results

Conclusions

Background

Various adjunct therapies are available for wound healing in addition to standard care. Topical oxygen therapy (TCOT) is one such novel therapy. We conducted a systematic review and meta-analysis to evaluate the role of TCOT in the healing of cutaneous wounds of any etiology.

Methods

The review was conducted on articles related to wounds treated with TCOT identified through PubMed, MEDLINE/OVID, Cochrane, and Google Scholar. We included randomized controlled trials, double-arm prospective studies, single-arm prospective studies, case-control series, and case reports published on or after 2012. Only articles addressing TCOT were included; other forms of oxygen delivery were excluded. We aimed to evaluate the proportion of wounds completely healed, the percent decrease in wound area of those not completely healed, the recurrence of wounds after treatment, and effects on pain and ulcer rating scales.

Results

A total of 22 articles were included in this review. The results showed that TCOT has a significant salutary effect on complete wound healing in case-control studies (odds ratio, 4.48; 95% confidence interval, 2.05-9.77; P < .001; I² = 76.34%) and in single-arm studies (pooled prevalence, 0.48 [48.0%]; 95% confidence interval, 0.34-0.62; P < .001; I² = 86.58). However, no significant effect was observed for percent wound reduction, the difference in ulcer grade scores, or the difference in pain scores. Most of the included studies had a high risk of bias because they were not blinded, were single-arm studies, or were case reports.

Conclusions

Our findings indicate that TCOT can have a positive effect on wound healing when compared with standard care. However, owing to the lack of randomized, controlled trials or studies with comparable end points, a definitive conclusion on the full impact of TCOT on wound healing cannot be reached. More high-quality data are needed to definitively determine the effects of TCOT on wound healing, preferably from a comprehensive, randomized controlled trial.

Objective

Thirty-day readmission rates after surgery are being increasingly used as a quality performance metric. Readmission rates in vascular surgery are frequently reported to be higher than other surgical specialties, and many coordinated efforts have been developed at local and national levels to reduce avoidable readmissions.

Methods

We constructed a multi-pronged readmission reduction quality improvement (QI) initiative aimed at addressing the clinical drivers of readmission after vascular surgery. Proposed interventions were implemented in Plan-Do-Study-Act (PDSA) cycles. Interventions aimed to improve patient communication and included post-discharge phone calls; mandatory follow-up before 2 weeks, with in-person visits required for all groin incisions and ischemic lower extremity wounds; and protocolized distribution of “calling cards,” which contained emergency and routine contact information. The primary outcome measure was 30-day readmission rate.

Results

After implementation of a multi-modal QI initiative, there was a statistically significant decrease in the 30-day readmission rate, from 14.1% to 8.2% (P = .02). A slightly higher percentage of readmissions, 57%, occurred within the first 2 weeks of discharge.

Conclusions

The consensus-driven development and implementation of a QI protocol to reduce 30-day readmission, based on increased patient communication and more standardized patient follow-up, showed promising results at our institution. Further efforts to improve readmission should focus on decreasing barriers to patient-provider communication after discharge.

Objective

Existing medical care for peripheral arterial disease, aortic aneurysms, and other forms of noncoronary vascular disease fails to integrate mobility, pain levels, and other real-time patient-generated health data, instead relying on formal hospital- or clinic-based evaluations. Wearable technology, such as smartwatches, is increasingly common and offers an opportunity to improve care by allowing the collection and use of these types of data.

Methods

We searched English language publications in MEDLINE and reviewed some of our work to perform this narrative review of wearable technology for noncoronary vascular disease.

Results

A wide range of patient-generated data may be collected using wearable technology using a spectrum of devices and platforms. There is very limited but growing work using wearable technology focused on noncoronary vascular disease. Preoperative mobility monitoring, reduction of postdischarge readmission after lower limb revascularization, and improvement of medication compliance are important examples of potential applications. We also identified several barriers to widespread use and acceptance of wearables such as patient acceptance, medical team burden, and data useability.

Conclusions

Wearable devices, such as smartwatches, offer the potential to fundamentally alter the management of noncoronary vascular disease by collecting real-time patient-generated data. There are several promising applications such as perioperative monitoring and medication compliance. Additional work on regulatory issues, cost-effectiveness, workflow integration, and acceptance by patients and clinicians will need to be completed before widespread use of wearables.

Mentorship is a cornerstone of a successful career in medicine and surgery. From medical school through our career, the opportunity to receive feedback, guidance, and support from mentors helps to shape our decisions, both clinical and professional, plays a role in our success. As vascular surgeons pivot from trainee to practicing surgeon, the nature and structure of their mentoring relationship will likely change as well. The purpose of this article was to outline the different types of mentoring, the ways in which it can be impactful in your career, and common barriers encountered among both mentors and mentees. We review the data that support the value of mentors to young vascular surgeons and offer resources available to individuals from the trainee to midcareer levels to make for lasting and productive mentor-mentee relationships.